Cardiac Catheterization

The purpose of the rotation is to gain an understanding of coronary anatomy and hemodynamics and to acquire the technical, cognitive and motor skills required to gain venous and arterial access and to perform coronary angiography.

The trainee will develop and be expected to demonstrate expertise in the following aspects related to the procedure including:

1. Understanding the appropriateness of procedure. The trainee should understand the indications for right and left heart catheterization, right ventricular endocardial biopsy, and be able to estimate the risk and benefit of procedures performed. Knowledge of comorbid factors that increase the risk of a procedure should be demonstrated.
2. Obtaining informed consent. The trainees should communicate the risk and benefits of a procedure in a manner that is understood by the patient and address questions raised by the patient. In situations where the patient cannot give informed consent, the trainee should obtain consent from appropriate sources.
3. Administering anesthesia. The trainee should demonstrate knowledge of the pharmacology of medications used for conscious sedation, contraindications for their use, side effects, and the treatment of side effects. The trainee should develop the skills to make the patient comfortable during an examination, follow the degree of sedation, and recognize and treat complications. The trainee should develop skills in obtaining vascular access to the internal jugular, subclavian and femoral veins as well as the femoral artery and brachial artery.
4. Coronary angiography and ventriculography. The trainee should develop skill in the injection of contrast material for angiography; recognize the potential complications of the use of x-ray contrast material. The trainee should develop a high level of competence in the interpretation of hemodynamic data and angiographic data.
5. Pericardiocentesis. The trainee should be able to understand the indications and potential risks of cardiac pericardiocentesis. He should demonstrate skill in performing the procedure.
6. Evaluating and treating complications. The trainee should have full knowledge of the potential complications of the procedures of diagnostic catheterization, the mechanisms for monitoring complications when suspected, and full knowledge of the appropriate treatment of these complications.
7. Right ventricular endocardial biopsy. The trainee should have full understanding of the indications for diagnostic endocardial biopsy and should have skill in performing this procedure both from the internal jugular and femoral venous approach. The trainee should have understanding of the potential complications and be prepared for emergent pericardiocentesis should complications arise.

During the first two years of training the fellow will aim to acquire the cognitive and motor skills to perform left and right heart catheterization. A minimum of six months is dedicated to this area, four at University of Iowa Hospitals & Clinics and two at the VA. In addition during the two months of inpatient CVICU rotations, the CVICU fellow will participate in invasive procedures on patients admitted or transferred to the CVICU. All procedures are performed under the direct supervision of an attending. The fellow is also expected to learn the indications for coronary intervention and post-intervention management. Fellows with an interest in interventional cardiology will be offered advanced training in this field. Overall, the cardiac catheterization laboratory experience will prepare most fellows for level 2 certification (8 months cardiac catheterization laboratory experience and at least 300 invasive diagnostic procedures).

Duties and responsibilities include the following:

1. The fellow will evaluate the inpatients or outpatients referred for cardiac catheterization and complete the pre-cath work up. The fellow will see all inpatients referred for cardiac catheterization on the ward or unit to which the patient is admitted.
2. The fellow will evaluate each patient prior to performing any invasive procedure. This evaluation will include reviewing all pertinent paperwork (H&P, labs, non-invasive studies, etc), perform a focused physical exam, ensure informed consent properly obtained, and answer any questions from the patient or family members.
3. The fellow will discuss cases with the cath lab attending
4. The fellow will arrive at least 30 minutes before the first scheduled case in order to review any outstanding lab data or answer any last minute questions.
5. The fellow will perform all cath lab procedures under the supervision of the cath lab attending physician
6. The fellow will complete the post-procedure paperwork (post-cath orders, brief note for chart, dictate the formal cath report, etc).
7. The fellow will call the house staff and the responsible cardiology fellow (on the consult, CVICU or CHF service) with results and to discuss any pertinent management issues or complications.
8. The fellow will perform a post-procedure groin check, review results, and answer any questions that the patient or their family members may have related to the procedure. Post-cath inpatients must be seen by the end of the procedure day for a post-procedure groin check.
9. The fellow will prepare a case for presentation at the weekly Cath Conference.
10. The fellow may assist the interventional staff with PCI cases if needed.
11. The fellow will maintain a complete and accurate log of all procedures performed.
12. The fellow will screen all outpatient referrals for cardiac catheterization and enter orders for the procedure if appropriate.

The fellow will review all cases with the cath lab attending prior to performing any procedure. All invasive cardiac procedures will be performed under the direct supervision of an invasive or interventional attending cardiologist.

Learning Objectives:

1. Learn the indications and contraindications of cath lab procedures. (B)
2. Learn to recognize and treat immediate cath lab complications. (A, B)
3. Become proficient in the technical aspects of coronary and peripheral angiography, right and left heart catheterization, pericardiocentesis, and temporary pacemaker placement. (B)
4. Learn the indications for and gain exposure to coronary PTCA and stenting. (B)
5. Learn and understand the protocols for correct performance and interpretation of invasive hemodynamic studies, including dobutamine valve studies, intracardiac shunt assessment, pericardial tamponade, and restrictive versus constrictive physiology. (B)
6. earn proper radiation safety. (B)
7. Develop an academic approach to the proper utilization of invasive cardiac testing. (A, B, C)
8. Gain an appreciation for the role of the Cath Lab staff members, including the technicians, nurses, and administrative staff. (D, E, F)
9. Progress toward the specific training requirements for the desired level of certification as outlined by COCATS 3. (B)

It is important to emphasize that the actual number of procedures required to accomplish clinical competence in cardiac catheterization is somewhat arbitrary, because there is individual variation in cognitive, analytical, and manual-dexterity skills. The listed numbers are therefore the minimum requirements anticipated to properly train the average cardiology fellow, and individual fellows may be required to perform additional procedures as determined by the Cath Lab supervising physician. Minimum training standards for cardiac catheterization are as follows:

Junior Fellows (first year fellows)

Junior fellows will perform history and physical examinations on all patients who are to undergo cardiac catheterization. They will obtain informed consent on the patients and review the case with the cardiac catheterization faculty in an effort to plan for the procedure. They will obtain vascular access and emphasis will be given to the technical aspect of the procedure with the catheterization staff. They will perform coronary artery contrast injection while the staff performs panning.

Senior Fellows (second year fellows and above)

In addition to the goals and objectives of junior fellows, senior fellows will be given more independence and will expand emphasis to the panning of cases with junior fellows and/or staff.

CATS Training Requirements for Diagnostic Cardiac Catheterization

At University of Iowa Hospitals & Clinics, the patient population that presents for cath lab procedures consists of male and female patients from various ethnic and socioeconomic backgrounds. Patients presenting to the Cath Lab for procedures have a variety of cardiac disorders, including coronary artery disease, valvular heart disease, congestive heart failure, and pericardial disease. Clinical encounters include pre-procedure evaluations in the ambulatory surgery unit and on the inpatient wards, performing the requested procedure, and providing any immediate post-procedure follow-up. Procedures performed include left and right heart catheterization, coronary and peripheral angiography, percutaneous peripheral and coronary intervention, pericardiocentesis, and temporary pacemaker placement.

The fellow will review each patient’s history and planned procedure with the attending. The attending will supervise the fellow during the procedure, and the fellow will assume progressive levels of responsibility as his or her skill level improves. The attending will review all procedure data with the fellow after the procedure is completed. Fellows on the cardiac cath rotation are expected to attend the weekly cardiac cath conference and also present cases at the joint TCV – cardiac cath conference.

1. The goals and objectives for the rotation will be verbally communicated at the beginning of the rotation.
2. The fellow’s progress will be reviewed verbally mid-rotation.
3. A standard fellow evaluation form will be completed by the attending at the end of the rotation.
4. The final evaluation by the supervising physician will be based on the fulfillment of the rotation objectives as determined by:
5. Personal observation during interaction with the fellow while performing Cath Lab procedures.
   1. Evidence of literature reviews appropriate for the individual patient and topic.
   2. Evidence of ability to perform appropriate pre-procedure evaluation.
   3. Evidence of ability to properly select patients for testing.
   4. Competent performance of cardiac procedures relative to the fellow’s level of training.
   5. Correct interpretation of procedure data obtained.
   6. Evidence of ability to provide appropriate post-procedure care.
   7. Feedback from Cath Lab staff members, other healthcare providers, and patients.

• University of Iowa Hardin Medical Library (Up to Date, electronic journals including New England Journal of Medicine, Circulation, Journal of the American College of Cardiology, Journal of the American Medical Association and Medline)
• www.cardiosource.com
• Heart Disease: A Textbook of Cardiovascular Medicine (9th edition) Eugene Braunwald, editor
• Baim and Grossman’s Cardiac Catheterization, Angiography, and Intervention (7th edition)
• The Cardiac Catheterization Handbook; Morton Kern (4th edition)
• www.scai.org